I regularly see women coming in for a complaint of pelvic organ prolapse, a “dropped bladder” or “uterine prolapse” who have very little observable in the way of prolapse. I always try to establish whether or not a woman actually feels tissue protruding or is simply feeling pressure and heaviness around her vagina and pelvis. There is a big difference between having true prolapse of the bladder, uterus, or posterior vagina and having pain in those areas. It is critically important to differentiate the two. Sometimes, patients will have both prolapse and musculoskeletal pain. I make it my mission to explain to them in detail the fact that while I can repair their anatomic prolapse, I can not eliminate their muscle spasm-related pain. Sometimes, following surgery, muscle spasm pain can become worse.
I have seen women coming in for consultation after having had multiple diagnostic studies including CT scans, MRIs, colonoscopies, cystoscopies, laparoscopies, all to no avail. Sometimes they are told it is their uterus, or their ovaries, or their bladder, or all of the above. It is incredibly frustrating to be in pain and be given various explanations and follow multiple treatment avenues only to end up with no improvement after a proposed treatment plan. Often, when I examine women and tell them that their pain is likely not related to prolapse, endometriosis, interstitial cystitis, irritable bowel syndrome, or ovarian cysts, I am greeted with skepticism and hostility, as though I am trying to put them off once again to something else. Nothing could be further from the truth. Experience is the best teacher, and I have learned about myofascial and neuropathic pain through many years of experience and study. So how does one determine that pain is related to muscles, bones and nerves rather than the pelvic organs? First, the pain is often preceded by some event (which is sometimes forgotten by the woman relating the history) such as a new exercise program, a trauma, a physical change, or a surgical procedure. I have seen it following a fall, starting a spin class, moving a couch, and lifting a dog. Second, it does not seem to follow the usual patterns for things like endometriosis (which is usually cyclical and often responds to hormonal manipulation), irritable bowel, or interstitial cystitis. Third, physical examination findings are classically revealing. I begin by checking all along the abdomen, the hip bones, pubic bones, and along the thighs. The pelvic muscles are palpated during the pelvic exam. If I can reproduce the pain experienced by the patient by touching one of the pelvic muscles and not by moving the uterus around, I can usually clinch the diagnosis. Certain muscle groups classically become inflamed when hip or knee problems are present. Often, women are surprised when I ask them about hip or knee problems when they haven’t complained about or discussed this with me. This doesn’t mean that one can only have one thing or the other. It is certainly possible to have more than one problem, for example, it is possible to have prolapse and myofascial pain, or endometriosis and myofascial pain. What’s important to understand is that treating the prolapse or the endometriosis doesn’t treat the myofascial pain. I prefer to start treatment nonsurgically prior to performing a surgical procedure when I am not convinced that surgery is likely to help.
The best approach to myofascial pain in my experience includes the following:
1. Physical therapy by a competent, well-trained therapist skilled and knowledgeable in pelvic floor physical therapy.
2. Hot baths in Epsom salts often provide some relief.
3. Muscle relaxants such as a low-dose Valium, baclofen, or tizanidine for use with therapy, as needed.
4. Identifying and eliminating the source of the pain (specific activities, hip or knee related pathology, etc).
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